The ABC of benign breast disease

Benign breast disease tends to take a back seat to breast cancer.

AARON NDHLUNI General surgeon, Kingsbury, Vincent Pallotti and Groote Schuur hospitals, Cape Town Aaron Ndhluni is a general surgeon with an interest in breast diseases. E-mail: [email protected]

Benign breast disease is common, although the incidence is sparsely Fibrocystic disease, more accurately called fibrocystic changes documented in the literature and is probably quite underestimated. (Fig. 1), is commonly seen in the breast. The term describes The main reason is that it is regarded as unimportant, with far pathological changes seen under the microscope and should not be more attention being focused on breast cancer. However, benign used to describe clinical findings. The histological changes include breast disease is far more common than breast cancer. There is varying amounts of fibrosis and cysts. It is generally accepted that now increasing interest because patients demand investigation and approximately 90% of women have fibrocystic changes, and that treatment of their symptoms. these are more pronounced in women of reproductive age. For many women such changes are normal, without an identifiable cause. Symptoms of benign breast disease Fibrocystic breast disease does not increase the risk of developing The clinical presentation of benign breast diseases includes one or breast cancer. more of the following symptoms: • breast lump • swelling or thickening • erythema • pain • nipple discharge or nipple change. Aberrations of normal development and involution (fibrocystic disease), breast pain and nipple discharges are common, and these will be reviewed. Benign breast disease is far more common than breast cancer.

Fig. 1. Fibrocystic changes. Aberrations of normal development and involution (ANDI) Breast pain (mastalgia) Breast pain is by far the most common reason for referral of Many so-called diseases of the breast are now regarded more patients to a breast clinic or specialist surgeons, and accounts for accurately as aberrations of normal development and involution. up to 50% of the patients seen. Nomenclature contributes to the The vast majority of premenopausal women experience a degree problem, with various terms such as mastodynia, mastitis and of breast discomfort and nodularity prior to menstruation. In the fibrocystic disease being used. Mastalgia is the most commonly majority of cases this amounts to little more than an inconvenience used and the most widely accepted term. Mild premenstrual and as such is regarded as a normal physiological process. Some breast pain is very common and affects most women at some time women, however, present with severe distressing symptoms. The or another. Mastalgia is an amplification of usual breast pain, predominant symptoms are breast pain, breast lumps and lumpiness presenting with greater frequency and severity. It is important to and feeling of fullness in the breasts. Nipple discharge that is often stress that mastalgia is a symptom and does not imply any specific greenish-brown in colour and breast cysts are also common. In pathological process any more than pain in other sites of the body. the past this was described as fibrocystic disease. Unfortunately there is poor correlation between the breast symptoms and the histological features. In some cases there is no specific histological Aetiology of mastalgia abnormality. Various aetiological factors have been implicated for mastalgia: • hyperoestrogenism

October 2009 Vol.27 No.10 CME 453 Benign breast disease

• abnormal fluid retention The reason for many referrals by general in cola, tea, and coffee), chocolate, and dairy practitioners is anxiety and fear of breast products. Relief may not be immediate, but • abnormal prolactin secretion cancer on the part of the patient, the parent symptoms generally improve within 3 - 4 • excessive caffeine ingestion or her doctor. It is therefore important not months. only to treat the symptoms but also to allay • inadequate essential fatty acid intake Evening primrose oil (a mixture of linoleic any fears that may exist. It is imperative to and linolenic acid) has been shown to be • psychoneurosis emphasise that mastalgia does not imply any effective in patients with cyclical mastalgia. neoplastic process. • medication (Table I) It is regarded by most patients as a natural Mastalgia that seems to be related to homeopathic substance whose only • age at first live birth menstrual cycle changes is usually mild, and significant side-effect is nausea. • nulliparity reassurance of its benign nature may be all Danazol is an antigonadotropin agent that that is necessary, along with firm brassiere • breast feeding. may be used as a second-line agent (after support and, possibly, the use of mild evening primrose oil) to manage adult A vast majority of clinical studies have failed analgesics. Underlying precipitating factors, women with severe refractory mastalgia at a to demonstrate significant differences in such as marijuana or other drug use, should dose of 200 - 400 mg daily. It has no proven levels of serum progesterone, oestradiol or be eliminated. Some patients benefit from benefit in adolescent girls. It has a number of prolactin among women who have breast avoidance of methylxanthines (i.e. caffeine potential adverse reactions, including weight pain and those who do not. There is a weak causal relationship with some drugs. Table I. Medication associated with mastalgia Mastalgia may be related to infection, malignancy, or extramammary conditions Common such as muskuloskeletal chest wall pain Oral contraceptives (Tietze syndrome or costochondritis), cervical spine disease, cardiac disease, or Hormone replacement therapy others. Therefore a careful assessment is Antidepressants necessary to identify the underlying cause Digoxin of the pain. A primary breast cancer should Methyldopa be ruled out because it is the leading cancer among women. Spironolactone Chlorpromazine Fibrocystic breast Other Amphetamines disease does not Anabolic steroids increase the risk Busulfan (and other chemotherapeutic agents) of developing Cimetidine breast cancer. Clomiphene Corticosteroids Insulin There are two distinct types of mastalgia – cyclical and non-cyclical. Cyclical mastalgia Isoniazid (and other antituberculosis drugs) is breast pain with a definite association Ketoconazole with the menstrual cycle, while non-cyclical Marijuana mastalgia is unrelated to the monthly Reserpine cycle. Because of the cyclical relationship to the menstrual cycle, cyclical mastalgia is Spironolactone generally found in premenopausal women, Testosterone with the commonest age of presentation Tricyclic antidepressants being 15 - 40 years. This pain is frequently, but not always, bilateral. Non-cyclical mastalgia, on the other hand, occurs in both pre- and postmenopausal women. It Table II. Medication used to treat mastalgia has a more chronic presentation and tends to be unilateral. Sometimes the pain is Simple analgesia well localised. Non-cyclical mastalgia has Non-steroidal anti-inflammatory drugs a higher relationship with extramammary Evening primrose oil causes. Vitamin E Treatment of mastalgia Flaxseed When a woman presents with mastalgia, a Magnesium thorough history and physical examination Oral contraceptives are necessary to rule out any underlying Danazol pathology. Mammography, breast ultra- sound or breast biopsy may be warranted Tamoxiphen for diagnostic purposes. Bromocriptine

454 CME October 2009 Vol.27 No.10 Benign breast disease gain, acne, amenorrhoea, masculinisation than a millimeter thick) is introduced with hirsutism, voice change, reduction Table III. Causes of nipple into the duct itself and manipulated to in breast size and teratogenicity. When discharge look at the lining of the duct system. No treating mastalgia one should therefore incision is made. This enables detection of always remember the classic dictum: ‘first Physiological small tumours, intraduct papillomas and do no harm’. Galactorrhoea some other benign changes. A normal ductoscopy has high reassurance value. Other treatment modalities include oral Mammary duct ectasia contraceptives which may improve (or Intraduct papilloma When there is blood-stained discharge, worsen) breast pain; bromocriptine; microdochotomy (excision of the Carcinoma vitamin E supplementation (600 IU/d) offending duct) should be performed. which has anecdotal, but no research- Purulent discharge from breast abscess The commonest finding is an intraduct based, support for improvement; vitamin Drugs (e.g. ranitidine, phenothiazines, papilloma. Copious spontaneous dis- E cream application; flaxseed; and topical oral contraceptives) charge should also be managed in a similar non-steroidal anti-inflammatory gel. manner. However, in most patients It is important to ascertain whether reassurance with careful follow-up is all Secretions the nipple discharge is blood-stained, that is indicated. (discharge) from spontaneous, unilateral or bilateral, or Further reading from a single duct. If there is an associated 1. Hughes et al. Aberrations of normal the nipple are not lump, then the investigation thereof development and involution (ANDI): a becomes paramount and the discharge new perspective on pathogenesis and unusual, or even secondary. The presence of blood and nomenclature of benign breast disorders. necessarily a drainage from a single duct indicates a Lancet 1987; ii: 1316-1319. potentially serious cause. 2. Hughes et al. Benign Disorders and Diseases of sign of disease. the Breast: Concepts and Clinical Management. Physiological nipple discharge and London: Bailliere Tindall, 1989. galactorrhoea (secretion of milk not 3. Miltenburg DM, Speights VO. Benign breast Surgery has virtually no role in the related to pregnancy or lactation) are by disease. Obstet Gynecol Clin North Am 2008; treatment of mastalgia although there is far the most common. In older women, 35(2): 285-300. some success in excision of focal areas of mammary duct ectasia is commoner. 4. Greydanus DE et al. Breast disorders in mastalgia when associated with a localised However, the most important causes are children and adolescents. Prim Care Clin Office Pract 2006; 33: 455-502. lump as part of ANDI. Occasionally intraduct papilloma (benign) and very patients with a long history of unresponsive rarely breast cancer. 5. Millet AV, Dirbas FM. Clinical management mastalgia demand consideration of of breast pain: a review. Obstet Gynecol Surv mastectomy to release them from their 2002; 57(7): 451-461. discomfort. This should be avoided. 6. Rosolowich V, Saettler E, Szuck B, et al. In most patients Mastalgia. J Obstet Gynaecol Can 2006; reassurance with 28(1):49-71. 7. Meisner AL, Fekrazad H, Royce ME. Breast Nipple discharge careful follow- disease: benign and malignant. Med Clin N Nipple discharge is a common presenting Am 2008; 92: 1115-1141. symptom. Patients with nipple discharge up is all that is 8. Mansel RE, Wisbey JR, Hughes LE. Controlled often fear cancer, and the discharge may trial of antigonadotrophin danazol in painful cause annoyance and social embarrassment. indicated. nodular benign breast disease. Lancet 1982; 1: Since the breast is a gland, secretions 928-931. (discharge) from the nipple are not unusual, Management of nipple discharge 9. Santen RJ, Mansel R. Benign breast disorders. nor even necessarily a sign of disease. Nipple Investigation with cytology and radiology N Engl J Med 2005; 353: 275-285. discharge comes in a variety of colours and has poor yield and is disappointing. 10. Beach RK. Galactorrhoea (nipple discharge) textures. Possible causes of nipple discharge in adolescent girls. In: Berman S, ed. Pediatric Some centres perform ductoscopy. This Decision Making, 4th ed. Philadelphia: are listed in Table III. is where a tiny fibre-optic scope (less Mosby, 2003: p.32.

In a nutshell • Breast pain and nipple discharge are common presenting symptoms. • Aetiological factors for mastalgia are poorly understood. • Allaying anxiety and fears about breast cancer is important. • Surgery plays a very small role in the treatment of mastalgia. • The vast majority of nipple discharges are physiological. • Blood-stained, single-duct, spontaneous discharge is worrisome. • Cytology and radiology have a poor yield in nipple discharge.

October 2009 Vol.27 No.10 CME 455